1 / 27

Diabetes in Pregnancy: Care Principles

Diabetes in Pregnancy: Care Principles. Elizabeth Guevara, FNP-BC Maternal Fetal Medicine - DM. Why Do We Care?. Insulin Requirements. Blood Glucose Ranges. GDM Background & Incidence.

apu
Download Presentation

Diabetes in Pregnancy: Care Principles

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Diabetes in Pregnancy: Care Principles Elizabeth Guevara, FNP-BC Maternal Fetal Medicine - DM

  2. Why Do We Care?

  3. Insulin Requirements

  4. Blood Glucose Ranges

  5. GDM Background & Incidence 1964: Formal diagnostic criteria established for gestational diabetes based on mother’s increased risk of future development of diabetes  lifetime risk of diabetes exceeded 70% GDM incidence in U.S. formerly ~2-10%, now estimated ~18% with the ADA-endorsed IADPSG 2011 criteria Change from 2-step diagnosis (50 gm screen with 100 gm 3-hr GTT confirmation) to 75 gm 2-hr GTT

  6. GDM: Recurrence Risk • 35-80% risk of GDM recurrence • Higher risk of recurrence if: • Parity: >1 in 1st GDM pregnancy • Greater infant birth weight in 1st GDM pregnancy • Maternal obesity (BMI > 30) • Early GDM (<24 wks) in 1st GDM pregnancy • Insulin requirement in 1st GDM pregnancy • Weight gain > 7 kg in 1st GDM pregnancy • Interval between pregnancies < 24 months

  7. GDM: Future T2DM Risk “The closer you are to diabetes in pregnancy, the sooner you will become diabetic.” • Variable quoted rates of conversion to T2DM • 22% some degree of glucose intolerance in immediate postpartum period (2-hr GTT @ 6-8 wks PP) • 3.2% impaired fasting glucose (IFG) • 11% impaired glucose tolerance (IGT) • 2.1% both IFG and IGT • 5.8% (~5-10%) overt T2DM • 20-50% risk over the 10 years following pregnancy: marked increased risk in first 5 years then plateaus after 10 years • 35-60% chance of developing T2DM in the following 10-20 years

  8. GDM: PP T2DM Risk Factors Impaired glucose tolerance postpartum Elevated fasting glucose during pregnancy: FPG > 121 in pregnancy  risk 21-fold Obesity, especially abdominal obesity Postpartum weight gain Early GDM diagnosis (<20-24 wks gestation) Insulin use/requirement during pregnancy Physical Inactivity Diet higher in fat content (38-40% of total calories) High glycemic index / low fiber diet

  9. GDM: Modifiable Risk Factors • Breastfeeding for at least 6 months • Postpartum Weight loss • Return to pre-pregnancy weight by 3 months PP • Lose 5-10% of body weight • Lose at least 10 pounds prior to next pregnancy • Regular physical activity

  10. Basic New Patient Teaching Medical Nutrition Therapy (MNT) Exercise Blood Glucose Meter Use & Testing Schedules

  11. Medical Nutrition Therapy • Food Groups • “Carbohydrates” (starches) • Dairy • Fruits • Vegetables • Protein • Fats • Portion Amounts • Measuring Cups • Hand Jive

  12. Carbohydrates/Starches • Portion = 15 grams total carbohydrates • Examples • Bread: 1 slice whole grain • Tortilla: 1 corn or wheat (6”) • Rice & Pasta: 1/3 cup • Beans: ½ cup • Hot Cereal: ½ cup • Potato: 1 small or ½ medium (or ½ cup total) • Winter Squash, Corn, Peas, Sweet Potato: ½ cup • Crackers: 6 saltines • English Muffin: ½

  13. Milk / Calcium-Rich Foods • Portion = 15 grams total carbohydrates • Examples • Milk (~1%): 8 oz. • Yogurt: 6 oz. plain or light yogurt (no fructose in ingredients)

  14. Fruits • Portion = 15 grams total carbohydrates • Examples: highly variable amounts • Apple, Nectarine, Orange: 1 small • Banana: 1 small…in reality ½ normal banana • Blueberries: ¾ cup • Grapefruit: ½ large • Grapes: 17 small • Mango: ½ cup • Papaya & Melon: 1 cup • Pineapple: ¾ cup • Strawberries & Watermelon: 1 ¼ cups

  15. Vegetables • Portion = 5 grams total carbohydrates • Amounts: 1 cup raw or ½ cup cooked • Exceptions: • Jicama: ½ cup • Vegetable Juice: ½ cup • “Starchy” vegetables: corn, peas, potato, sweet potato / yam, winter squash (acorn, butternut, kabocha, pumpkin, etc.) – count as Carbohydrate

  16. Protein • Portion ~ 7 grams protein • Examples • Canned Meats: ¼ cup • Cheese: 1 oz. • Cottage Cheese: ¼ cup • Eggs: 1 whole or 2 egg whites • Meats/Fish/Fowl: 1 oz. • Peanut Butter: 1 tbsp natural • Tofu: ½ cup

  17. Fats • Portion ~ 4.5 grams unsaturated fat • Examples • Avocado: 2 tbsp • Olives: 8 black, 10 green • Nuts • Almonds: 6 whole • Peanuts: 10 whole • Pecans: 2 whole • Walnuts: 2 whole • Vegetable Oil: olive, canola 1 tsp • Avoid All Animal (Saturated) Fats

  18. Free Foods • Portion = less than 5 grams total carbohydrates (<20 calories) • Examples • Artificial Sweetener (no saccharin: crosses the placenta) • Broth (low sodium) • Decaffeinated Coffee & Tea • Drink Mix (sugar free) • Gelatin (sugar free) • Herbs (dried & fresh) • Lemon • Lettuce • Mushroom • Radish

  19. Foods to Eliminate • Avoid during pregnancy to prevent inducing hyperglycemia • Examples • Bagel / Muffin • Coffee Creamer / Flavored Milk • Condiments / Sauces: BBQ Sauce, Ketchup, Teriyaki Sauces • Fruit Juices / Flavored Drinks / Sodas • Ice Cream / Frozen Yogurt • Instant Cereals* • Jam / Jelly • Sugars: Honey, Sugar, Syrup • Sweets: Cake, Candy, Cookies, Custard, Donuts, Pies, Pudding

  20. Basic Tenets of MNT in Pregnancy • 3 Meals & 3 Snacks Daily • Meals • Breakfast: 1-2 carbs, 1 protein, 1+ vegetables, ?1 fat • 1 egg, 1 whole wheat toast, spinach, ?oil • No milk or fruit • Lunch: 3 carbs, 4 proteins, 2+ vegetables, ?1 fat • 3 chicken tacos with salsa, side salad, ?avocado • No milk or fruit • Dinner: 3 carbs, 4 proteins, 2+ vegetable, ?1 fat • 1 medium baked potato, grilled fish, ½ cup corn, broccoli, ?oil • No milk or fruit

  21. MNT for Diabetes in Pregnancy • 3 Meals & 3 Snacks Daily • Snacks: between each meal and ~30-60 minutes before bed • 1st 2 snacks: 1 milk, 1 fruit, 1 protein, ?1 fat • 8 oz. milk or 6 oz. yogurt, ½ banana, 1 cheese stick (mozzarella), ?walnuts • No “carbohydrate” foods • Last snack: 1 dairy, 1 carb, 1 protein, ?1 fat • 8 oz. milk, ½ sandwich: 1 whole wheat bread, turkey, lettuce, tomato ?mayo • No fruit

  22. MNT Timing • Goal: no more than 10 hours between last snack & breakfast • Avoid elevated fasting blood glucose • Avoid ketone production • Meals are usually ~3 hours apart • 0800 Breakfast • 1000 Snack • 1300 Lunch • 1600 Snack • 1900 Dinner • 2200 Snack • 2230 Go to sleep • Nothing to eat until breakfast

  23. Exercise • Minimum goal = 30 minutes daily • Standard recommendation: 10 minutes after each meal • Exercise after eating increases glucose uptake by muscles • Decreases postprandial blood glucose level • Type of exercise • Baseline level of exercise prior to pregnancy • Avoid exercise that might cause trauma • Exercise class: let instructor know to tailor routine for pregnancy

  24. SMBG Testing • The minimum 4: all types of diabetes in pregnancy • Fasting • 1 Hour PC (time from first bite of food) • The extra 2: for patients on MDI insulin (3-4x daily) • AC Dinner • AC Last Snack • Type 1 Diabetes: often 2-4 am test & AC lunch • Additional tests • Hypoglycemia symptoms • When blood glucose result is radically different than anticipated

  25. Putting it Together Patient Log Brought To Each Visit!

  26. Labs, Diagnostics, Delivery • Hemoglobin A1C • Ultrasounds for Growth • 30 weeks: on medication • 36-37 weeks: intended vaginal delivery • Fetal Monitoring / Nonstress Test • 32-36 weeks: weekly testing if on meds • 40-41 weeks: no medication • Vaginal Delivery Timing • 39-40 weeks: on medication • 40-41 week: no medication & good control

  27. It Goes Beyond Pregnancy ++ + + + + =Healthier Outcomes for Individual, Familial & Societal Health

More Related